Comprehensive Cardiovascular and Renal Protection in Patients with Type 2 Diabetes.

Type 2 diabetes (T2DM) is one of the main public health care problems worldwide. It is associated with a marked increased risk of developing atherosclerotic vascular disease, heart failure, chronic kidney disease and death. It is essential to act during the early phases of the disease, through the intensification of lifestyle changes and the prescription of those drugs that have been shown to reduce these complications, with the aim not only of achieving an adequate metabolic control, but also a comprehensive vascular risk control. In this consensus document, developed by the different specialists that treat these patients (endocrinologists, primary care physicians, internists, nephrologists and cardiologists), a more appropriate approach in the management of patients with T2DM or its complications is provided. A particular focus is given to the global control of cardiovascular risk factors, the inclusion of weight within the therapeutic objectives, the education of patients, the deprescription of those drugs without cardiovascular benefit, and the inclusion of GLP-1 receptor agonists and SGLT2 inhibitors as cardiovascular protective drugs, at the same level as statins, acetylsalicylic acid, or renin angiotensin system inhibitors.

Safety of Non-Vitamin K Antagonist Oral Anticoagulants in Clinical Practice: Focus on Rivaroxaban in Stroke Prevention in Patients With Atrial Fibrillation.

Despite direct oral anticoagulants (DOACs) have overcome the most relevant limitations of vitamin K antagonists, many patients with atrial fibrillation are not receiving the appropriate anticoagulant therapy. In addition, when patients are anticoagulated with DOACs, some of them are not taking the dose recommended in the summary of product characteristics. This may be related, at least in part, to the concern about the applicability of findings from randomized clinical trials to real-life patients. In this context, performing studies in daily clinical practice to assess the efficacy and safety of DOACs in real-world setting is mandatory. The aim of this review is to update the current evidence regarding safety of rivaroxaban in clinical practice. The Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET-AF) showed that rivaroxaban was at least as effective as warfarin for preventing stroke or systemic embolism, with similar rates of major bleeding but with lesser risk of intracranial and fatal bleedings. Data from noninterventional studies and registries have confirmed the good results of ROCKET-AF. Even more, rates of bleeding may be inferior in real-life patients, since they have a lower risk profile than those included in ROCKET-AF.

Frailty predicts major bleeding within 30days in elderly patients with Acute Coronary Syndrome.

OBJECTIVE: Bleeding in ACS patients is an independent marker of adverse outcomes. Its prognostic impact is even worse in elderly population. Current bleeding risk scores include chronological age but do not consider biologic vulnerability. No studies have assessed the effect of frailty on major bleeding. The aim of this study is to determine whether frailty status increases bleeding risk in patients with ACS. METHODS: This prospective and observational study included patients aged ≥75years admitted due to type 1 myocardial infarction. Exclusion criteria were severe cognitive impairment, impossibility to measure handgrip strength, cardiogenic shock and limited life expectancy due to oncologic diseases. The primary endpoint was 30-day major bleeding defined as a decrease of ≥3g/dl of haemoglobin or need of transfusion. RESULTS: A total of 190 patients were included. Frail patients (72, 37.9%) were older, with higher comorbidity features and with a higher CRUSADE score at admission. On univariate analysis, frailty predicted major bleeding during 30-day follow-up despite less frequent use of a P2Y12 inhibitor (66.2% vs 83.6%, p=0.007) and decreased catheterisation rate (69.4% vs 94.1%, p<0.001). Major bleeding was associated with increased all-cause mortality at day 30 (18.2% vs 2.5%, p<0.001). On multivariate analysis, frailty was an independent predictor for major bleeding. CONCLUSION: Frailty phenotype, as a marker of biological vulnerability, is an independent predictor of major bleeding in elderly patients with ACS. Frailty can play an important role in bleeding risk stratification and objective indices should be integrated into routine initial evaluation of these patients.

Frailty is a short-term prognostic marker in acute coronary syndrome of elderly patients.

BACKGROUND: Frailty is a biological condition that reflects a state of decreased physiological reserve and vulnerability to stressors. The role of frailty in acute coronary syndrome patients has not been fully explored. Our study aims to assess the prevalence of frailty and its impact on in-hospital adverse outcomes of patients aged ⩾75 years admitted for acute coronary syndrome. METHODS: This prospective, observational study included patients aged ⩾75 years admitted due to type 1 myocardial infarction in four tertiary hospitals. Frailty was assessed by the SHARE-FI index. The primary endpoint was the combination of in-hospital death or non-fatal myocardial (re)infarction. Secondary endpoints included the assessment of individual rates of (re)infarction, mortality, stroke, major bleeding and the combination of in-hospital death, (re)infarction and mortality. RESULTS: A total of 202 patients were analysed. Frail patients (n=71, 35.1%) were older, more often women, had higher rates of comorbidities, and a higher risk profile according to GRACE, TIMI and CRUSADE scores at admission. The primary endpoint was significantly more frequent among frail patients (9.9% vs. 1.5%; P=0.006), as well as the combination of death, myocardial infarction and stroke (11.3% vs. 1.5%; P=0.002), driven mainly by a higher mortality rate (8.5% vs 0.8%; P=0.004). On multivariate analysis, frailty phenotype was an independent predictor of major adverse cardiac events (odds ratio 7.13; 95% confidence interval 1.43-35.42). CONCLUSIONS: Over one third of elderly patients with high-risk acute coronary syndrome are frail. Frailty phenotype is an important and independent prognostic marker in these patients.

Clinical Experience with Diltiazem in the Treatment of Cardiovascular Diseases.

UNLABELLED: Cardiovascular diseases are the leading cause of death in the world. Coronary artery diseases, atrial fibrillation or hypertensive heart disease, are among the most important cardiovascular disorders. Hypertension represents a significant risk factor for cardiovascular mortality; thus, control of high blood pressure has become a priority to prevent major complications. Although the choice of drugs for treating hypertension remains controversial, extensive clinical evidences point to calcium channel blockers as first-line agents. Diltiazem, a non-dihydropyridine calcium channel blocker, is an effective and safe antihypertensive drug, alone or in combination with other agents. Diltiazem lowers myocardial oxygen demand through a reduction in heart rate, blood pressure, and cardiac contractility, representing also a good alternative for the treatment of stable chronic angina. Furthermore, diltiazem reduces conduction in atrioventricular node, which is also useful for heart rate control in patients with atrial fibrillation. In this review, clinical experts highlight studies on diltiazem effectiveness and safety for the treatment of several cardiovascular diseases and make evidence-based recommendations regarding the management of diltiazem in the clinical practice. FUNDING: Lacer Spain.

Selección de temas de actualidad en riesgo vascular y rehabilitación cardiaca 2015 / Vascular risk and cardiac rehabilitation 2015: a selection of topical issues

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Etiología y prevención de la fibrilación auricular / Etiology and prevention of atrial fibrillation

La fibrilación auricular, una de las arritmias más frecuentes, suele aparecer en situaciones clínicas que dilatan las aurículas, aumentan la presión en el interior de estas cavidades o afectan a su pared, como ocurre con algunos procesos inflamatorios. En este artículo se revisan los principales agentes relacionados con el incremento del riesgo de fibrilación auricular, aspecto íntimamente conectado con las opciones actualmente disponibles para prevenirla (AU)

Atrial fibrillation, one of the most common cardiac arrhythmias, usually appears in clinical conditions that either cause atrial dilation, increase interatrial pressure or affect the atrial walls. Such conditions can occur with some inflammatory processes. This article provides a review of the principal factors associated with an increased risk of atrial fibrillation - factors that are closely linked to current strategies for preventing the arrhythmia (AU)

Respuesta al ECG de junio de 2015 / Response to ECG, June 2015

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ECG de junio de 2015 / ECG, June 2015

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